Janette W. Powell, PT, BEd (Eng), BAppSc (Pty), OCS, STC, EMT-B
Peter A. Huijbregts, PT, MSc, MHSc, DPT, OCS, MTC, FAAOMPT, FCAMT
Abstract: This article systematically reviews the available research on concurrent criterion-related validity of physical examination tests for the diagnosis of acromioclavicular joint (ACJ) dysfunction. A literature search yielded four research studies on the topic of concurrent criterion-related validity of physical examination tests of the ACJ. These studies had various methodological shortcomings. Methodological scores on the STARD (Standards for Reporting of Diagnostic Accuracy) criteria yielded scores from 1/22 to 16/22. All studies examined pain provocation tests only. The currently available best research evidence supports the inclusion of a number of tests with a specific interpretation in a physical examination format for the diagnosis of painful ACJ dysfunction. A negative finding on the cross-body adduction test, tenderness on palpation of the ACJ, and the Paxinos sign may serve to rule out a painful ACJ dysfunction. A positive finding on the active compression test, the cross-body adduction test, and the acromioclavicular resisted extension test may serve to rule in a painful ACJ dysfunction. A positive finding on all three tests for the cross-body adduction, active compression, and resisted acromioclavicular extension may be relevant when the physical therapist is considering a medical-surgical referral and associated higher-risk interventions. This review indicates that future research is required 1) to evaluate the diagnostic utility of the gold standard tests used in the studies retrieved; 2) to examine the reliability and concurrent criterion-related validity (with validated gold standard tests) of these and other physical tests and history items commonly used in the diagnosis of ACJ lesions, both isolated and in the form of multi-test regimens; and 3) to study predictive validity of findings on tests and multi-test regimens for ACJ dysfunction coupled to outcomes with diagnosis-specific (orthopedic manual) physical therapy, medical, and surgical interventions.
Key Words: Concurrent Criterion-Related Validity, Acromioclavicular Joint, Physical Examination, Systematic Review, STARD Criteria
Shoulder pain is a common reason for patients to seek physical therapy (PT) services. Dysfunction of the acromioclavicular joint (ACJ) is a common component of shoulder pain1-7. ACJ separations (grades I and II) have been described as accounting for 45% of all athletic shoulder injuries4. The incidence of injuries to the clavicle and the associated joints has been reported to be as high as 23/1000 athletic exposures for ice hockey and 17/1000 athletic exposures for lacrosse5. The prevalence of atraumatic osteolysis has been reported to be as high as 27% in weightlifters6. Kiner7 noted that over half of the ACJ injuries occur in the under-30 population. The ACJ is one of the most frequently injured joints in certain sports, e.g., football, ice hockey, skiing, and rugby1,2.
Table 1 contains pathologies that may affect the ACJ1-3,8-11. Dislocations of the ACJ account for 12% of all dislocations affecting the shoulder girdle1. Rapid degeneration of the intra-articular disc commences in the second decade of life and is significant by the fourth decade2,3. A lack of intra-articular disc development may play a significant role in the development of osteoarthritis. The ACJ is also prone to inflammatory, septic, and crystalline arthropathy2,3. The deltoid, trapezius, and pectoralis major muscles may contribute to pathologic conditions including osteolysis of the distal clavicle via compressive forces that these muscles place on the ACJ during repeated forceful contraction2.
There is increasing focus within the medical and allied health community to substantiate current practice with scientific evidence. This is often referred to as evidence-based practice (EBP). EBP stresses the examination and clinical application of scientific research evidence. Within the EBP paradigm, the emergence of new evidence in literature can and should change the way patients are evaluated and treated. Sackett et al12 described EBP as “...the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients...” Current research commonly delves into the reliability and accuracy of diagnostic tests (including the history and physical examination), the predictive value of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. Such research has the potential to invalidate previously accepted diagnostic tests and therapeutic and preventive interventions and to replace them with new ones that are more accurate, efficient, effective, and safer12. EBP is constructed from the best available research evidence, clinician expertise, and patients’ values12. This composite approach to diagnosis, prognosis, and management holds the potential to optimize and progressively evolve the evaluation and treatment provided in the medical community.
In this article we discuss the evidence base for diagnosis of ACJ dysfunction, specifically research into the concurrent criterion-related validity of physical examination tests for the ACJ. We first briefly review the statistical concept of concurrent criterion-related validity and the associated relevant statistics, followed by a narrative description of the studies that have researched ACJ physical examination test validity. We then discuss research validity of the studies reviewed both in a narrative format and based on the Standards for Reporting of Diagnostic Accuracy (STARD) statement13,14. A clinical interpretation with a suggestion for a physical examination format based on best available evidence as discussed in this article and suggestions for future research conclude the article.